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Huang W, Smith AT, Korotun M, Iacono A, Wang J. Lung Transplantation in a New Era in the Field of Cystic Fibrosis. Life (Basel) 2023; 13:1600. [PMID: 37511977 PMCID: PMC10381966 DOI: 10.3390/life13071600] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/03/2023] [Revised: 07/08/2023] [Accepted: 07/19/2023] [Indexed: 07/30/2023] Open
Abstract
Lung transplantation for people with cystic fibrosis (PwCF) is a critical therapeutic option, in a disease without a cure to this day, and its overall success in this population is evident. The medical advancements in knowledge, treatment, and clinical care in the field of cystic fibrosis (CF) rapidly expanded and improved over the last several decades, starting from early pathology reports of CF organ involvement in 1938, to the identification of the CF gene in 1989. Lung transplantation for CF has been performed since 1983, and CF now accounts for about 17% of pre-transplantation diagnoses in lung transplantation recipients. Cystic fibrosis transmembrane conductance regulator (CFTR) modulators have been the latest new therapeutic modality addressing the underlying CF protein defect with the first modulator, ivacaftor, approved in 2012. Fast forward to today, and we now have a growing CF population. More than half of PwCF are now adults, and younger patients face a better life expectancy than they ever did before. Unfortunately, CFTR modulator therapy is not effective in all patients, and efficacy varies among patients; it is not a cure, and CF remains a progressive disease that leads predominantly to respiratory failure. Lung transplantation remains a lifesaving treatment for this disease. Here, we reviewed the current knowledge of lung transplantation in PwCF, the challenges associated with its implementation, and the ongoing changes to the field as we enter a new era in the care of PwCF. Improved life expectancy in PwCF will surely influence the role of transplantation in patient care and may even lead to a change in the demographics of which people benefit most from transplantation.
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Affiliation(s)
- Wei Huang
- Department of Medicine, Donald and Barbara Zucker School of Medicine at Hofstra/Northwell, Hempstead, NY 11549, USA
| | - Alexander T Smith
- Department of Medicine, Donald and Barbara Zucker School of Medicine at Hofstra/Northwell, Hempstead, NY 11549, USA
| | - Maksim Korotun
- Department of Medicine, Donald and Barbara Zucker School of Medicine at Hofstra/Northwell, Hempstead, NY 11549, USA
- Division of Pulmonary, Critical Care, and Sleep Medicine, Department of Medicine, Donald and Barbara Zucker School of Medicine at Hofstra/Northwell, Hempstead, NY 11549, USA
| | - Aldo Iacono
- Department of Medicine, Donald and Barbara Zucker School of Medicine at Hofstra/Northwell, Hempstead, NY 11549, USA
- Division of Pulmonary, Critical Care, and Sleep Medicine, Department of Medicine, Donald and Barbara Zucker School of Medicine at Hofstra/Northwell, Hempstead, NY 11549, USA
| | - Janice Wang
- Department of Medicine, Donald and Barbara Zucker School of Medicine at Hofstra/Northwell, Hempstead, NY 11549, USA
- Division of Pulmonary, Critical Care, and Sleep Medicine, Department of Medicine, Donald and Barbara Zucker School of Medicine at Hofstra/Northwell, Hempstead, NY 11549, USA
- Institute of Health System Science, Feinstein Institute for Medical Research, Northwell Health, Manhasset, NY 11030, USA
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2
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Grassi G, Cairoli E, Gentile LMS, Chiodini I, Zampogna M, Ghielmetti A, Morlacchi LC, Rossetti V, Rosso L, Righi I, Nosotti M, Arosio M, Blasi F, Eller Vainicher C. Bone Disease in Long-Term Lung Transplant Survivors. Life (Basel) 2023; 13:life13040928. [PMID: 37109457 PMCID: PMC10146054 DOI: 10.3390/life13040928] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/06/2023] [Revised: 03/09/2023] [Accepted: 03/29/2023] [Indexed: 04/05/2023] Open
Abstract
Background: During the first two years after lung transplantation (LTx), the incidence of fragility fractures (FX) is estimated to be 15–50% and it is lower in patients with cystic fibrosis (CF) as compared with other end-stage lung diseases (nCF). The aim of our study is to compare the skeletal outcomes, after the first 2 years post-LTx, in long-term survivors with CF and nCF. Materials and Methods: We evaluated the FX rate, the changes in bone mineral density (BMD) and trabecular bone score (TBS) in 68 patients (38 CF and 30 nCF) who underwent LTx in our center and with a follow-up after LTx longer than 5 years (7.3 ± 2.0 years). Results: After the second year post-LTx: (i) the FX rate was lower than during the first two years post-LTx (4.4 vs. 20.6%, p = 0.004), with no difference between CF and nCF patients (5.3 vs. 3.3%, p = 0.589); (ii) BMD at lumbar spine, femoral neck and total hip remained stable (−1.6 ± 1.0 vs. −1.4 ± 1.1, p = 0.431, −1.8 ± 0.9 vs. −1.9 ± 0.9, p = 0.683, −1.5 ± 0.9 vs. −1.4 ± 0.9, p = 0.678, respectively) as well as TBS (1.200 ± 0.124 vs. 1.199 ± 0.205, p = 0.166). Conclusions: After the second year post-LTx, the skeletal complications become less frequent and have similar incidence in patients with CF and nCF.
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Affiliation(s)
- Giorgia Grassi
- Unit of Endocrinology, Fondazione IRCCS Cà Granda Ospedale Maggiore Policlinico, 20122 Milan, Italy
- Department of Clinical Sciences and Community Health, University of Milan, 20123 Milan, Italy
| | - Elisa Cairoli
- Unit for Bone Metabolism Diseases and Diabetes, Lab of Endocrine and Metabolic Research, Istituto Auxologico Italiano, IRCCS, 20122 Milan, Italy
| | | | - Iacopo Chiodini
- Unit of Endocrinology, Ospedale Niguarda Cà Granda, 20162 Milan, Italy
- Department of Medical Biotechnology and Translational Medicine, University of Milan, 20123 Milan, Italy
| | - Marta Zampogna
- Department of Clinical Sciences and Community Health, University of Milan, 20123 Milan, Italy
| | - Alberto Ghielmetti
- Department of Clinical Sciences and Community Health, University of Milan, 20123 Milan, Italy
| | - Letizia Corinna Morlacchi
- Respiratory Unit, Cystic Fibrosis Adult Center, Fondazione IRCCS Ca’ Granda Ospedale Maggiore Policlinico, 20122 Milan, Italy
| | - Valeria Rossetti
- Respiratory Unit, Cystic Fibrosis Adult Center, Fondazione IRCCS Ca’ Granda Ospedale Maggiore Policlinico, 20122 Milan, Italy
| | - Lorenzo Rosso
- Department of Pathophysiology and Transplantation, University of Milan, 20123 Milan, Italy
- Thoracic Surgery and Lung Transplant Unit, Fondazione IRCCS Ca’ Granda Ospedale Maggiore Policlinico, 20122 Milan, Italy
| | - Ilaria Righi
- Thoracic Surgery and Lung Transplant Unit, Fondazione IRCCS Ca’ Granda Ospedale Maggiore Policlinico, 20122 Milan, Italy
| | - Mario Nosotti
- Department of Pathophysiology and Transplantation, University of Milan, 20123 Milan, Italy
- Thoracic Surgery and Lung Transplant Unit, Fondazione IRCCS Ca’ Granda Ospedale Maggiore Policlinico, 20122 Milan, Italy
| | - Maura Arosio
- Unit of Endocrinology, Fondazione IRCCS Cà Granda Ospedale Maggiore Policlinico, 20122 Milan, Italy
- Department of Clinical Sciences and Community Health, University of Milan, 20123 Milan, Italy
| | - Francesco Blasi
- Respiratory Unit, Cystic Fibrosis Adult Center, Fondazione IRCCS Ca’ Granda Ospedale Maggiore Policlinico, 20122 Milan, Italy
- Department of Pathophysiology and Transplantation, University of Milan, 20123 Milan, Italy
| | - Cristina Eller Vainicher
- Unit of Endocrinology, Fondazione IRCCS Cà Granda Ospedale Maggiore Policlinico, 20122 Milan, Italy
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Macrae TA, Lazo J, Viduya J, Florez R, Dewey K, Gao Y, Singer JP, Hays SR, Golden JA, Kukreja J, Greenland JR, Calabrese DR. Frailty and genetic risk predict fracture after lung transplantation. Am J Transplant 2023; 23:214-222. [PMID: 36695698 PMCID: PMC10037703 DOI: 10.1016/j.ajt.2022.11.017] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/06/2022] [Revised: 11/15/2022] [Accepted: 11/29/2022] [Indexed: 01/07/2023]
Abstract
Fractures negatively impact quality of life and survival. We hypothesized that recipient frailty score and genetic profile measured before transplant would predict risk of fracture after lung transplant. We conducted a retrospective cohort study of bone mineral density (BMD) and fracture among lung transplant recipients at a single center. The association between predictors and outcomes were assessed by multivariable time-dependent Cox models or regression analysis. Among the 284 participants, osteoporosis and fracture were highly prevalent. Approximately 59% of participants had posttransplant osteopenia, and 35% of participants developed at least 1 fracture. Low BMD was associated with a polygenic osteoporosis risk score, and the interaction between genetic score and BMD predicted fracture. Pretransplant frailty was associated with risk for spine and hip fracture, which were not associated with chronic lung allograft dysfunction or death. Chest fractures were the most frequent type of fracture and conferred a 2.2-fold increased risk of chronic lung allograft dysfunction or death (time-dependent P < .001). Pneumonia, pleural effusions, and acute rejection frequently occurred surrounding chest fracture. Pretransplant frailty and recipient genotype may aid clinical risk stratification for fracture after transplant. Fracture carries significant morbidity, underscoring the importance of surveillance and osteoporosis prevention.
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Affiliation(s)
- Trisha A Macrae
- Department of Medicine, University of California, San Francisco, California, USA
| | - Jose Lazo
- Department of Clinical Pharmacy, University of California, San Francisco, California, USA
| | - Judy Viduya
- Department of Clinical Pharmacy, University of California, San Francisco, California, USA
| | - Rebecca Florez
- Department of Clinical Pharmacy, University of California, San Francisco, California, USA
| | - Katherine Dewey
- Department of Clinical Pharmacy, University of California, San Francisco, California, USA
| | - Ying Gao
- Department of Medicine, University of California, San Francisco, California, USA
| | - Jonathan P Singer
- Department of Medicine, University of California, San Francisco, California, USA
| | - Steven R Hays
- Department of Medicine, University of California, San Francisco, California, USA
| | - Jeffrey A Golden
- Department of Medicine, University of California, San Francisco, California, USA
| | - Jasleen Kukreja
- Department of Surgery, University of California, San Francisco, California, USA
| | - John R Greenland
- Department of Medicine, University of California, San Francisco, California, USA; Medical Service, Veterans Affairs Health Care System, San Francisco, California, USA
| | - Daniel R Calabrese
- Department of Medicine, University of California, San Francisco, California, USA; Medical Service, Veterans Affairs Health Care System, San Francisco, California, USA.
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4
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Dury S, Ancel J, Ravoninjatovo B, Lambrecht I, Perotin JM, Mulette P, Lebargy F, Salmon JH, Deslée G, Launois C. Clinical relevance of low bone density in cystic fibrosis adult patients: A pilot study. Medicine (Baltimore) 2023; 102:e32227. [PMID: 36607849 PMCID: PMC9829254 DOI: 10.1097/md.0000000000032227] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/07/2023] Open
Abstract
Survival improvement in cystic fibrosis (CF) is associated with more frequent long-term complications, including CF related bone disease (CFBD). Impact of CFBD on global health outcome remains poorly described. We aimed to assess the relationship between low bone mineral density (BMD) and spinal pain, disability, and quality of life in CF adult patients. This monocentric cross-sectional study with prospective data collection was conducted from November 2016 to December 2019 in the Department of Respiratory Diseases at the University Hospital of Reims (NCT02924818). BMD was assessed by X-ray absorptiometry (DXA). Disability was assessed by the Health Assessment Questionnaire (HAQ). Quality of life was assessed by both the St George's Respiratory Questionnaire and the Cystic Fibrosis Questionnaire for teenagers and adults (CFQ 14+). Forty patients were analyzed, 68% of men, with a median age of 25 years, a median body mass index of 21 kg/m² and a median FEV1% of 54%. Nine patients (23%) had spinal pain. Ten patients (25%) had a low BMD. Compared with patients with normal BMD, patients with low BMD had a significantly lower BMI (22 vs 19 kg/m²; P = .006) and less vitamin D supplementation (33% vs 0%; P = .035). Low BMD was not associated with spinal pain, disability and quality of life. Low BMD is frequent in CF, affecting 1-quarter of adult patients. No significant association was found between low BMD and spinal pain, disability or quality of life.
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Affiliation(s)
- Sandra Dury
- Department of Respiratory Diseases, Reims University Hospital
- EA7509 IRMAIC, University of Reims Champagne-Ardenne
- * Correspondence: Sandra Dury, Department of Respiratory Diseases, Maison Blanche University Hospital, 45, rue DE Cognacq-Jay, 51 092 Reims cedex, France (e-mail: )
| | - Julien Ancel
- Department of Respiratory Diseases, Reims University Hospital
| | | | | | - Jeanne-Marie Perotin
- Department of Respiratory Diseases, Reims University Hospital
- INSERM UMRS 1250, Reims University Hospital, Reims
| | - Pauline Mulette
- Department of Respiratory Diseases, Reims University Hospital
| | - François Lebargy
- Department of Respiratory Diseases, Reims University Hospital
- EA7509 IRMAIC, University of Reims Champagne-Ardenne
| | | | - Gaëtan Deslée
- Department of Respiratory Diseases, Reims University Hospital
- INSERM UMRS 1250, Reims University Hospital, Reims
| | - Claire Launois
- Department of Respiratory Diseases, Reims University Hospital
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5
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Ebeling PR, Nguyen HH, Aleksova J, Vincent AJ, Wong P, Milat F. Secondary Osteoporosis. Endocr Rev 2022; 43:240-313. [PMID: 34476488 DOI: 10.1210/endrev/bnab028] [Citation(s) in RCA: 69] [Impact Index Per Article: 34.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/02/2020] [Indexed: 02/07/2023]
Abstract
Osteoporosis is a global public health problem, with fractures contributing to significant morbidity and mortality. Although postmenopausal osteoporosis is most common, up to 30% of postmenopausal women, > 50% of premenopausal women, and between 50% and 80% of men have secondary osteoporosis. Exclusion of secondary causes is important, as treatment of such patients often commences by treating the underlying condition. These are varied but often neglected, ranging from endocrine to chronic inflammatory and genetic conditions. General screening is recommended for all patients with osteoporosis, with advanced investigations reserved for premenopausal women and men aged < 50 years, for older patients in whom classical risk factors for osteoporosis are absent, and for all patients with the lowest bone mass (Z-score ≤ -2). The response of secondary osteoporosis to conventional anti-osteoporosis therapy may be inadequate if the underlying condition is unrecognized and untreated. Bone densitometry, using dual-energy x-ray absorptiometry, may underestimate fracture risk in some chronic diseases, including glucocorticoid-induced osteoporosis, type 2 diabetes, and obesity, and may overestimate fracture risk in others (eg, Turner syndrome). FRAX and trabecular bone score may provide additional information regarding fracture risk in secondary osteoporosis, but their use is limited to adults aged ≥ 40 years and ≥ 50 years, respectively. In addition, FRAX requires adjustment in some chronic conditions, such as glucocorticoid use, type 2 diabetes, and HIV. In most conditions, evidence for antiresorptive or anabolic therapy is limited to increases in bone mass. Current osteoporosis management guidelines also neglect secondary osteoporosis and these existing evidence gaps are discussed.
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Affiliation(s)
- Peter R Ebeling
- Department of Medicine, School of Clinical Sciences, Monash University, Clayton, Victoria 3168, Australia.,Department of Endocrinology, Monash Health, Clayton, Victoria 3168, Australia
| | - Hanh H Nguyen
- Department of Medicine, School of Clinical Sciences, Monash University, Clayton, Victoria 3168, Australia.,Department of Endocrinology, Monash Health, Clayton, Victoria 3168, Australia.,Department of Endocrinology and Diabetes, Western Health, Victoria 3011, Australia
| | - Jasna Aleksova
- Department of Endocrinology, Monash Health, Clayton, Victoria 3168, Australia.,Hudson Institute of Medical Research, Clayton, Victoria 3168, Australia
| | - Amanda J Vincent
- Department of Endocrinology, Monash Health, Clayton, Victoria 3168, Australia.,Monash Centre for Health Research and Implementation, School of Public Health and Preventative Medicine, Monash University, Clayton, Victoria 3168, Australia
| | - Phillip Wong
- Department of Medicine, School of Clinical Sciences, Monash University, Clayton, Victoria 3168, Australia.,Department of Endocrinology, Monash Health, Clayton, Victoria 3168, Australia.,Hudson Institute of Medical Research, Clayton, Victoria 3168, Australia
| | - Frances Milat
- Department of Medicine, School of Clinical Sciences, Monash University, Clayton, Victoria 3168, Australia.,Department of Endocrinology, Monash Health, Clayton, Victoria 3168, Australia.,Hudson Institute of Medical Research, Clayton, Victoria 3168, Australia
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6
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Han S, Gong F, Xue Y, Wang C, Qi X. Development of a Chemiluminescence Assay for Total N-Terminal Propeptide of Type I Collagen and Its Evaluation in Lung Transplantation. JOURNAL OF ANALYTICAL METHODS IN CHEMISTRY 2022; 2022:2711414. [PMID: 35047228 PMCID: PMC8763551 DOI: 10.1155/2022/2711414] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Figures] [Subscribe] [Scholar Register] [Received: 07/01/2021] [Revised: 10/12/2021] [Accepted: 10/15/2021] [Indexed: 06/14/2023]
Abstract
Serum P1NP, one of the important biomarkers for bone turnover, is commonly used for the prediction of bone fracture and the prognosis of osteoporosis after therapy. We developed a P1NP chemiluminescence assay and evaluated changes in bone metabolism markers in lung transplant patients. The screened 2 P1NP antibodies with constructed antigens and α-1 chain antigens expressed by the Corynebacterium glutamate expression system were applied into assay development. The assay performance was evaluated to examine the reliability. A normal Q-Q plot was used to establish male reference interval. Changes of bone metabolism markers before and after lung transplantation in 19 patients were evaluated. The linear factor R of P1NP reagent was greater than 0.99. The limit of detection was 3.32 ng/ml. The precision of the three batches of P1NP reagents was lower than 8%. Method comparison with Roche P1NP reagent showed that the correlation coefficient R 2 was 0.91. In the monitoring of bone mass in a short time, bone metabolism markers can better indicate the change of bone mass, while the traditional bone mineral density detection is lagging behind the bone metabolism markers. P1NP and β-CrossLap to bone mass change in patients after lung transplantation, and P1NP and β-CrossLap are very good clinical markers for bone mass monitoring.
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Affiliation(s)
- Shuang Han
- The Affiliated Hospital of Jiangnan University, Department of Pathology, Wuxi, China
- School of Medicine, Jiangnan University, Wuxi, China
| | - Fang Gong
- The Affiliated Hospital of Jiangnan University, Department of Pathology, Wuxi, China
- School of Medicine, Jiangnan University, Wuxi, China
| | - Yifeng Xue
- The Affiliated Wuxi People's Hospital of Nanjing Medical University, Department of Laboratory Medicine, Wuxi, China
| | - Chunxin Wang
- The Affiliated Wuxi People's Hospital of Nanjing Medical University, Department of Laboratory Medicine, Wuxi, China
| | - Xiaowei Qi
- The Affiliated Hospital of Jiangnan University, Department of Pathology, Wuxi, China
- School of Medicine, Jiangnan University, Wuxi, China
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7
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Ng E, Topliss DJ, Paraskeva M, Paul E, Sztal-Mazer S. The Utility of Prophylactic Zoledronic Acid in Patients Undergoing Lung Transplantation. J Clin Densitom 2021; 24:581-590. [PMID: 33189560 DOI: 10.1016/j.jocd.2020.10.003] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/03/2020] [Revised: 10/11/2020] [Accepted: 10/12/2020] [Indexed: 11/18/2022]
Abstract
Osteoporosis is prevalent among lung transplant candidates and is exacerbated post-transplant by immunosuppressive therapy. Low bone mineral density (BMD) is a well-recognized surrogate for fragility fracture risk, which is associated with significant morbidity and mortality. Intravenous zoledronic acid (ZA) effectively reduces BMD loss and prevents fractures in postmenopausal osteoporosis. Many groups, ours included, prophylactically treat lung transplant recipients (LTR) with bisphosphonates, but no documented consensus currently exists. Our protocol comprises ZA every 6-months from transplant wait-listing, with interval reassessment to guide ongoing treatment. We evaluate the impact of a dose of ZA within 6 months of transplantation on BMD and fracture occurrence. A retrospective analysis was performed on all adult LTR from April 2012 to October 2014, of which 60 met our inclusion criteria. LTR who received ZA within 6 months of transplantation (n = 37) were compared to those who did not (n = 23), and followed up for a minimum of three years. Outcome measures were BMD change at the lumbar spine and femur (primary), and fracture occurrence (secondary). LTR treated with ZA within 6 months of transplantation experienced a median BMD change of +8.11% at the lumbar spine and +1.39% at the femur, compared to -1.20% and -3.92%, respectively, in LTR who did not receive a ZA dose within 6 months of transplantation (p = 0.002 & p = 0.008 respectively). Our findings indicate that prophylactic ZA within 6 months of transplantation prevents BMD loss in LTR.
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Affiliation(s)
- Elisabeth Ng
- Department of Endocrinology and Diabetes, Alfred Health, Victoria, Australia.
| | - Duncan J Topliss
- Department of Endocrinology and Diabetes, Alfred Health, Victoria, Australia; Central Clinical School, Faculty of Medicine, Nursing and Health Sciences, Monash University, Victoria, Australia
| | - Miranda Paraskeva
- Central Clinical School, Faculty of Medicine, Nursing and Health Sciences, Monash University, Victoria, Australia; Department of Respiratory Medicine, Alfred Health, Victoria, Australia
| | - Eldho Paul
- School of Public Health and Preventive Medicine, Monash University, Victoria, Australia
| | - Shoshana Sztal-Mazer
- Department of Endocrinology and Diabetes, Alfred Health, Victoria, Australia; Central Clinical School, Faculty of Medicine, Nursing and Health Sciences, Monash University, Victoria, Australia; School of Public Health and Preventive Medicine, Monash University, Victoria, Australia
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8
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Impact of bone-active drugs and underlying disease on bone health after lung transplantation: A longitudinal study. J Cyst Fibros 2021; 20:e100-e107. [PMID: 34366281 DOI: 10.1016/j.jcf.2021.07.013] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/01/2020] [Revised: 04/15/2021] [Accepted: 07/24/2021] [Indexed: 11/23/2022]
Abstract
INTRODUCTION the effect of bone-active drugs on the risk of fragility fractures (Fx), bone mineral density (BMD) and trabecular bone score (TBS) changes in patients receiving lung transplantation (LTx) is largely unknown. This study assessed the bone-active drugs effect in patients undergoing LTx both with (CF) and without (nCF) cystic-fibrosis. METHODS We evaluated incident Fx, both clinical and morphometric vertebral Fx by spinal X-ray, BMD and trabecular bone score (TBS) in 117 patients (CF=50, nCF n = 67) before and 24-months after LTx. A bone-active therapy was proposed to all LTx candidates. RESULTS 83.8% of patients started a bone-active drug. Lumbar-spine (LS) T-score improved significantly only in treated patients (-1.4 ± 1.0 vs -2.0±1.0, p = 0.0001), whereas femur BMD and TBS remained stable in treated and not treated subjects. The rate of incident Fx was 15.3%, with no difference between treated and not treated patients. After LTx, LS T-score improved significantly only in nCF group (-1.3 ± 1.0 vs -1.8 ± 1.1, p = 0.0001), while femur remained stable in both nCF and CF groups. Patients with CF showed a significant Z-TBS increase (-3.6 ± 1.7 vs -3.0 ± 1.7, p = 0.019) and a lower Fx incidence as compared with nCF patients (4.1% vs 24.2%, p =0.003). Incident Fx were associated with nCF diagnosis (OR 7.300, CI95% 1.385-38.461, p = 0.019) regardless of prevalent Fx, previous glucocorticoid therapy and bone-active therapy introduced at least 6 months before LTx. CONCLUSIONS A prompt medical intervention helps in preventing BMD loss after LTx. As compared with nCF patients, CF patients show a TBS increase and a lower Fx risk after LTx.
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9
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[Osteoporosis in pneumological diseases : Joint guideline of the Austrian Society for Bone and Mineral Research (ÖGKM) and the Austrian Society for Pneumology (ÖGP)]. Wien Klin Wochenschr 2021; 133:155-173. [PMID: 34132916 PMCID: PMC8206904 DOI: 10.1007/s00508-021-01896-x] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 05/19/2021] [Indexed: 10/27/2022]
Abstract
Chronic inflammation induces proinflammatory cytokine cascades. In addition to systemic inflammation, hypoxemia, hypercapnia, a catabolic metabolism, gonadal or thyroid dysfunction, musculoskeletal dysfunction and inactivity as well as vitamin D deficiency contribute to an increased risk of fragility fractures. Iatrogenic causes of osteoporosis are long-term use of inhaled or systemic glucocorticoids (GC). Inhalative GC application in asthma is often indicated in childhood and adolescence, but interstitial lung diseases such as chronic organizing pneumonia, COPD, sarcoid or rheumatic diseases with lung involvement are also treated with inhalative or oral GC. In patients with cystic fibrosis, malabsorption in the context of pancreatic insufficiency, hypogonadism and chronic inflammation with increased bone resorption lead to a decrease in bone structure. After lung transplantation, immunosuppression with GC is a risk factor.The underlying pneumological diseases lead to a change in the trabecular and cortical bone microarchitecture and to a reduction in osteological formation and resorption markers. Hypercapnia, acidosis and vitamin D deficiency can accelerate this process and thus increase the individual risk of osteoporotic fragility fractures.A bone mineral density measurement with a T‑Score < -2.5 is a threshold value for the diagnosis of osteoporosis; in contrast the vast majority of all osteoporotic fractures occur with a T‑Score > -2.5. A history of low-trauma fracture indicates osteological therapy.All antiresorptive or anabolic drugs approved in Austria for the treatment of osteoporosis are also indicated for pneumological patients with an increased fragility fracture risk of bone fractures in accordance with the national reimbursement criteria.
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Abstract
PURPOSE OF REVIEW Over the past two decades, lung transplant has become the mainstay of treatment for several end-stage lung diseases. As the field continues to evolve, the criteria for referral and listing have also changed. The last update to these guidelines was in 2014 and several studies since then have changed how patients are transplanted. Our article aims to briefly discuss these updates in lung transplantation. RECENT FINDINGS This article discusses the importance of early referral of patients for lung transplantation and the concept of the 'transplant window'. We review the referral and listing criteria for some common pulmonary diseases and also cite the updated literature surrounding the absolute and relative contraindications keeping in mind that they are a constantly moving target. Frailty and psychosocial barriers are difficult to assess with the current assessment tools but continue to impact posttransplant outcomes. Finally, we discuss the limited data on transplantation in acute respiratory distress syndrome (ARDS) due to COVID19 as well as extracorporeal membrane oxygenation bridge to transplantation. SUMMARY The findings discussed in this article will strongly impact, if not already, how we select candidates for lung transplantation. It also addresses some aspects of lung transplant such as frailty and ARDS, which need better assessment tools and clinical data.
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11
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Durette G, Jomphe V, Bureau NJ, Poirier C, Ferraro P, Lands LC, Mailhot G. Long-term bone mineral density changes and fractures in lung transplant recipients with cystic fibrosis. J Cyst Fibros 2020; 20:525-532. [PMID: 34108100 DOI: 10.1016/j.jcf.2020.09.012] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/05/2020] [Revised: 09/08/2020] [Accepted: 09/29/2020] [Indexed: 11/26/2022]
Abstract
BACKGROUND Little is known about long-term bone mineral density (BMD) changes and fractures in lung transplant recipients with cystic fibrosis (CF). We examined femur and lumbar spine (LS) BMD changes in men and women with CF up to 10 years post-transplant and documented post-transplant fracture prevalence. METHODS Retrospective study of individuals who had undergone a lung transplant (2000-2015) and had a pre-transplant and at least one BMD measurement after transplant. Vertebral fractures were assessed on chest computed tomography scans and other fractures abstracted from medical records. RESULTS The cohort consisted of 131 individuals; 53% males, median age: 28 years [interquartile range: 24-35] and 31% having pre-transplant low bone mass. Most recipients were given bisphosphonates after transplant with proportion reaching 94% at 10 years. Up to 10 years post-transplant, men experienced positive or little change in LS BMD, indicating minimal loss from pre-transplant values. In contrast, women displayed negative changes in BMD up to 5 years post-transplant before recovering pre-transplant BMD values by 10 years. Similar patterns were observed at the femur BMD where men demonstrated a lower bone loss and faster recovery towards pre-transplant values than women. After transplant, 88% of recipients maintained their pre-transplant bone status, 3% experienced an improvement, mostly progressing from low bone mass to normal status whereas 9% had a deterioration of their pre-transplant bone status. Twenty-seven recipients suffered fractures in the post-transplant period. CONCLUSIONS These findings underline that lung recipients with CF remain at risk of skeletal fragility despite prompt initiation of post-transplant anti-osteoporosis therapy.
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Affiliation(s)
- Gabrielle Durette
- Department of Nutrition, Faculty of Medicine, Université de Montreal, 2405 Cote Sainte-Catherine Rd, Montreal, Quebec H3T 1A8, Canada
| | - Valérie Jomphe
- Lung Transplant Program, Centre Hospitalier de l'Université de Montréal, 900 Saint-Denis street (Pavillon R), Montreal, Quebec H2 × 0A9, Canada.
| | - Nathalie J Bureau
- Department of Radiology, Faculty of Medicine, Université de Montreal.
| | - Charles Poirier
- Lung Transplant Program, Centre Hospitalier de l'Université de Montréal, 900 Saint-Denis street (Pavillon R), Montreal, Quebec H2 × 0A9, Canada; Department of Medicine, Centre Hospitalier de l'Université de Montréal, 1058 St-Denis street, Montreal, Quebec H2 × 3J4, Canad.
| | - Pasquale Ferraro
- Lung Transplant Program, Centre Hospitalier de l'Université de Montréal, 900 Saint-Denis street (Pavillon R), Montreal, Quebec H2 × 0A9, Canada; Division of Thoracic Surgery, Department of Surgery, Centre Hospitalier de l'Université de Montréal, 1058 St-Denis street, Montreal, Quebec H2 × 3J4, Canada.
| | - Larry C Lands
- Lung Transplant Program, Centre Hospitalier de l'Université de Montréal, 900 Saint-Denis street (Pavillon R), Montreal, Quebec H2 × 0A9, Canada; Department of Pediatrics, Montreal Children's Hospital-McGill University Health Centre, Meakins Christie Laboratories, Research Institute of the McGill University Health Centre, 1001 Décarie boulevard, Montreal, Quebec H4A 3J1, Canada.
| | - Geneviève Mailhot
- Department of Nutrition, Faculty of Medicine, Université de Montreal, 2405 Cote Sainte-Catherine Rd, Montreal, Quebec H3T 1A8, Canada; Research Centre, CHU Sainte-Justine, 3175 Cote Sainte-Catherine Rd, Montreal, Quebec H3T 1C5, Canada.
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Caffarelli C, Tomai Pitinca MD, Alessandri M, Cameli P, Bargagli E, Bennett D, Fossi A, Bernazzali S, Gonnelli S. Timing of Osteoporotic Vertebral Fractures in Lung and Heart Transplantation: A Longitudinal Study. J Clin Med 2020; 9:jcm9092941. [PMID: 32933025 PMCID: PMC7565939 DOI: 10.3390/jcm9092941] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/13/2020] [Revised: 09/08/2020] [Accepted: 09/10/2020] [Indexed: 02/07/2023] Open
Abstract
Bone loss and bone fractures are common complications after organ transplantation. Many factors contribute to the pathogenesis of transplant osteoporosis, such as bone disease preceding transplantation, immunosuppressive medications, and nutritional and lifestyle factors. This study aimed to assess the incidence of vertebral fractures before and after lung and heart transplantation. This longitudinal study analyzed 213 electronic medical records of patients who underwent lung transplantation (n = 128) and heart transplantation (n = 85) at Siena University Medical Center between January 2000 and December 2018. In lung and heart transplant recipients, the bone mineral density in the femoral sub-regions show a significant decrease at post-transplantation and at follow up visits. In both lung and heart recipients, we found an increase in the fracture incidence in the first period after transplantation (19.5% vs. 50.4% in lung recipients; 9.6% vs. 25.7% in heart recipients). Moreover, in lung recipients, vertebral fractures were predicted primarily by age, BMD at the femur, and any history of fracture. In heart recipients, vertebral fractures were predicted only by history of fracture. Our study supports the recommendations for pre-transplant osteoporosis screening in patients undergoing lung transplants, and in the first period after transplantation in heart transplant recipients.
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Affiliation(s)
- Carla Caffarelli
- Department of Medicine, Surgery and Neuroscience, University of Siena, 53100 Siena, Italy; (M.D.T.P.); (M.A.); (S.G.)
- Correspondence: ; Tel.: +39-0577-585468; Fax: +39-0577-233446
| | - Maria D. Tomai Pitinca
- Department of Medicine, Surgery and Neuroscience, University of Siena, 53100 Siena, Italy; (M.D.T.P.); (M.A.); (S.G.)
| | - Mario Alessandri
- Department of Medicine, Surgery and Neuroscience, University of Siena, 53100 Siena, Italy; (M.D.T.P.); (M.A.); (S.G.)
| | - Paolo Cameli
- Respiratory Diseases and Lung Transplantation Unit, University of Siena, 53100 Siena, Italy; (P.C.); (E.B.); (D.B.); (A.F.)
| | - Elena Bargagli
- Respiratory Diseases and Lung Transplantation Unit, University of Siena, 53100 Siena, Italy; (P.C.); (E.B.); (D.B.); (A.F.)
| | - David Bennett
- Respiratory Diseases and Lung Transplantation Unit, University of Siena, 53100 Siena, Italy; (P.C.); (E.B.); (D.B.); (A.F.)
| | - Antonella Fossi
- Respiratory Diseases and Lung Transplantation Unit, University of Siena, 53100 Siena, Italy; (P.C.); (E.B.); (D.B.); (A.F.)
| | - Sonia Bernazzali
- Department of Cardiac Surgery, University of Siena, 53100 Siena, Italy;
| | - Stefano Gonnelli
- Department of Medicine, Surgery and Neuroscience, University of Siena, 53100 Siena, Italy; (M.D.T.P.); (M.A.); (S.G.)
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Risk Factors and Management of Osteoporosis Post-Transplant. ACTA ACUST UNITED AC 2020; 56:medicina56060302. [PMID: 32575603 PMCID: PMC7353876 DOI: 10.3390/medicina56060302] [Citation(s) in RCA: 17] [Impact Index Per Article: 4.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/25/2020] [Revised: 06/11/2020] [Accepted: 06/17/2020] [Indexed: 02/06/2023]
Abstract
Bone and mineral disorders are common after organ transplantation. Osteoporosis post transplantation is associated with increased morbidity and mortality. Pathogenesis of bone disorders in this particular sub set of the population is complicated by multiple co-existing factors like preexisting bone disease, Vitamin D deficiency and parathyroid dysfunction. Risk factors include post-transplant immobilization, steroid usage, diabetes mellitus, low body mass index, older age, female sex, smoking, alcohol consumption and a sedentary lifestyle. Immunosuppressive medications post-transplant have a negative impact on outcomes, and further aggravate osteoporotic risk. Management is complex and challenging due to the sub-optimal sensitivity and specificity of non-invasive diagnostic tests, and the underutilization of bone biopsy. In this review, we summarize the prevalence, pathophysiology, diagnostic tests and management of osteoporosis in solid organ and hematopoietic stem cell transplant recipients.
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14
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Anastasilakis AD, Tsourdi E, Makras P, Polyzos SA, Meier C, McCloskey EV, Pepe J, Zillikens MC. Bone disease following solid organ transplantation: A narrative review and recommendations for management from The European Calcified Tissue Society. Bone 2019; 127:401-418. [PMID: 31299385 DOI: 10.1016/j.bone.2019.07.006] [Citation(s) in RCA: 34] [Impact Index Per Article: 6.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/24/2019] [Revised: 07/07/2019] [Accepted: 07/08/2019] [Indexed: 02/08/2023]
Abstract
INTRODUCTION Solid organ transplantation is an established therapy for end-stage organ failure. Both pre-transplantation bone disease and immunosuppressive regimens result in rapid bone loss and increased fracture rates. METHODS The European Calcified Tissue Society (ECTS) formed a working group to perform a systematic review of existing literature on the consequences of end-stage kidney, liver, heart, and lung disease on bone health. Moreover, we assessed the characteristics of post-transplant bone disease and the skeletal effects of immunosuppressive agents and aimed to provide recommendations for the prevention and treatment of transplantation-related osteoporosis. RESULTS Characteristics of bone disease may differ depending on the organ that fails, but patients awaiting solid organ transplantation frequently depict a wide spectrum of bone and mineral abnormalities. Common features are a decreased bone mass and impaired bone strength with consequent high fracture risk, all of which are aggravated in the early post-transplantation period. CONCLUSION Both the underlying disease leading to end-stage organ failure and the immunosuppression regimens implemented after successful organ transplantation have detrimental effects on bone mass, quality and strength. Given existing ample data confirming the high frequency of bone disease in patients awaiting solid organ transplantation, we recommend that all transplant candidates should be assessed for osteoporosis and fracture risk and, if indicated, treated before and after transplantation. Since bone loss in the early post-transplantation period occurs in virtually all solid organ recipients and is associated with glucocorticoid administration, the goal should be to use the lowest possible dose and to taper and withdraw glucocorticoids as early as possible.
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Affiliation(s)
| | - Elena Tsourdi
- Department of Medicine III, Technische Universität Dresden Medical Center, Dresden, Germany; Center for Healthy Aging, Technische Universität Dresden Medical Center, Dresden, Germany
| | - Polyzois Makras
- Department of Endocrinology and Diabetes, 251 Hellenic Force & VA General Hospital, Athens, Greece
| | - Stergios A Polyzos
- First Department of Pharmacology, Medical School, Aristotle University of Thessaloniki, Thessaloniki, Greece
| | - Christian Meier
- Division of Endocrinology, Diabetology and Metabolism, University Hospital and University of Basel, Switzerland
| | - Eugene V McCloskey
- Centre for Metabolic Bone Diseases, University of Sheffield, Sheffield, UK; Centre for Integrated research in Musculoskeletal Ageing (CIMA), Mellanby Centre for Bone Research, University of Sheffield, Sheffield, UK
| | - Jessica Pepe
- Department of Internal Medicine and Medical Disciplines, "Sapienza" University, Rome, Italy
| | - M Carola Zillikens
- Bone Center, Department of Internal Medicine, Erasmus MC, Rotterdam, the Netherlands.
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15
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Sidhaye A, Goldswieg B, Kaminski B, Blackman SM, Kelly A. Endocrine complications after solid-organ transplant in cystic fibrosis. J Cyst Fibros 2019; 18 Suppl 2:S111-S119. [DOI: 10.1016/j.jcf.2019.08.019] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/08/2019] [Revised: 08/18/2019] [Accepted: 08/19/2019] [Indexed: 01/07/2023]
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16
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Vazquez Guillamet R. Chronic Obstructive Pulmonary Disease and the Optimal Timing of Lung Transplantation. MEDICINA-LITHUANIA 2019; 55:medicina55100646. [PMID: 31561607 PMCID: PMC6843760 DOI: 10.3390/medicina55100646] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Subscribe] [Scholar Register] [Received: 06/30/2019] [Revised: 09/17/2019] [Accepted: 09/23/2019] [Indexed: 11/29/2022]
Abstract
Chronic obstructive pulmonary disease (COPD) accounts for the largest proportion of respiratory deaths worldwide and was historically the leading indication for lung transplantation. The success of lung transplantation procedures is measured as survival benefit, calculated as survival with transplantation minus predicted survival without transplantation. In chronic obstructive pulmonary disease, it is difficult to show a clear and consistent survival benefit. Increasing knowledge of the risk factors, phenotypical heterogeneity, systemic manifestations, and their management helps improve our ability to select candidates and list those that will benefit the most from the procedure.
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17
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Cairoli E, Eller-Vainicher C, Morlacchi LC, Tarsia P, Rossetti V, Pappalettera M, Arosio M, Chiodini I, Blasi F. Bone involvement in young adults with cystic fibrosis awaiting lung transplantation for end-stage respiratory failure. Osteoporos Int 2019; 30:1255-1263. [PMID: 30798331 DOI: 10.1007/s00198-019-04893-z] [Citation(s) in RCA: 23] [Impact Index Per Article: 4.6] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/02/2018] [Accepted: 02/05/2019] [Indexed: 10/27/2022]
Abstract
UNLABELLED Patients with cystic fibrosis awaiting lung transplantation for end-stage respiratory failure have high prevalence of reduced bone mineral density and fragility fracture. Suboptimal 25-hydroxyvitamin D levels could significantly contribute to the development of cystic fibrosis-related bone disease. INTRODUCTION The assessment of the prevalence of cystic fibrosis-related bone disease (CFBD) and its associated risk factors in young adults with cystic fibrosis (CF) awaiting lung transplantation for end-stage respiratory failure. METHODS Clinical characteristics, bone mineral density (BMD), the parameters of calcium metabolism, including vitamin D (25OHVitD) levels, and the presence of fragility fractures were evaluated in 42 CF patients (24 females, age 34.0 ± 8.4 years) consecutively referred as lung transplant candidates. RESULTS Mean 25OHVitD levels (54.9 ± 26.2 nmol/L) were below the reference range and hypovitaminosis D (25OHVitD < 75 nmol/L) was found in 34 patients (81%) and daily calcium intakes (median 550 mg/day) were lower than recommended. A BMD below the expected range for age (Z-score of - 2.0 or lower) and at least one prevalent fragility fracture were found in 22 patients (52.4%) and 18 patients (45.2%), respectively. The coexistence of low BMD and the presence of fracture was observed in 13 patients (31.0%). In these patients, the prevalence of nephrolithiasis was higher than in the remaining ones (p = 0.046). The presence of kidney stones was associated with a worse bone status and with severe vitamin D deficiency. In the whole sample, femoral BMD Z-scores were directly correlated with albumin-adjusted calcium (p < 0.05) and 25OHVitD levels (p < 0.01). CONCLUSIONS Despite the improvement of CF care, CFBD is still highly prevalent in young adults awaiting lung transplantation for end-stage CF. Suboptimal 25OHVitD levels could significantly contribute to the development of CFBD. The presence of nephrolithiasis could be an additional warning about the need for a careful evaluation of bone health in CF patients.
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Affiliation(s)
- E Cairoli
- Unit for Bone Metabolism Diseases and Diabetes & Lab of Endocrine and Metabolic Research, Istituto Auxologico Italiano IRCCS, Milan, Italy.
- Department of Pathophysiology and Transplantation, University of Milan, Milan, Italy.
| | - C Eller-Vainicher
- Endocrinology Unit, Fondazione IRCCS Ca' Granda Ospedale Maggiore Policlinico, Milan, Italy
| | - L C Morlacchi
- Respiratory Unit & Cystic Fibrosis Adult Center, Fondazione IRCCS Ca' Granda Ospedale Maggiore Policlinico, Milan, Italy
| | - P Tarsia
- Respiratory Unit & Cystic Fibrosis Adult Center, Fondazione IRCCS Ca' Granda Ospedale Maggiore Policlinico, Milan, Italy
| | - V Rossetti
- Respiratory Unit & Cystic Fibrosis Adult Center, Fondazione IRCCS Ca' Granda Ospedale Maggiore Policlinico, Milan, Italy
| | - M Pappalettera
- Respiratory Unit & Cystic Fibrosis Adult Center, Fondazione IRCCS Ca' Granda Ospedale Maggiore Policlinico, Milan, Italy
| | - M Arosio
- Endocrinology Unit, Fondazione IRCCS Ca' Granda Ospedale Maggiore Policlinico, Milan, Italy
- Department of Clinical Science and Community Health, University of Milan, Milan, Italy
| | - I Chiodini
- Unit for Bone Metabolism Diseases and Diabetes & Lab of Endocrine and Metabolic Research, Istituto Auxologico Italiano IRCCS, Milan, Italy
- Department of Clinical Science and Community Health, University of Milan, Milan, Italy
| | - F Blasi
- Department of Pathophysiology and Transplantation, University of Milan, Milan, Italy
- Respiratory Unit & Cystic Fibrosis Adult Center, Fondazione IRCCS Ca' Granda Ospedale Maggiore Policlinico, Milan, Italy
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18
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Regard L, Lafoeste H, Martin C, Chassagnon G, Burgel PR. [Ageing with cystic fibrosis: Classical and emerging comorbidities in adults with cystic fibrosis]. REVUE DE PNEUMOLOGIE CLINIQUE 2018; 74:279-291. [PMID: 30316653 DOI: 10.1016/j.pneumo.2018.09.012] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 06/08/2023]
Abstract
Cystic fibrosis (CF) is a genetic disease with pulmonary involvement being predominant and often leading to respiratory failure and premature death. Non-pulmonary complications related to CF transmembrane conductance regulator (CFTR) defect are numerous and account for significant morbidity (exocrine pancreatic insufficiency, diabetes, CF-related liver disease, chronic sinusitis, osteoporosis). Improvement in patients' care led to a continuous increase in life expectancy, with a subsequent increase in the number of adult CF patients worldwide. Increased life expectancy comes with increased prevalence of CF-related comorbidities, but also with new emerging complications directly related to ageing (chronic kidney disease, cardiovascular risk factors, cancers). CFTR modulators might also contribute to modify the face of CF epidemiology and prognosis. Ageing with CF has become a challenge for CF patients and caregivers. This review summarizes classic and emerging comorbidities in the context of current growth and ageing of the CF population. It also addresses potential roles of CFTR modulators.
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Affiliation(s)
- L Regard
- Université Paris Descartes, Sorbonne Paris cité, 75006 Paris, France; Service de pneumologie, hôpital Cochin, AP-HP, 27, rue du Faubourg Saint-Jacques, 75014 Paris, France
| | - H Lafoeste
- Université Paris Descartes, Sorbonne Paris cité, 75006 Paris, France; Service de pneumologie, hôpital Cochin, AP-HP, 27, rue du Faubourg Saint-Jacques, 75014 Paris, France
| | - C Martin
- Université Paris Descartes, Sorbonne Paris cité, 75006 Paris, France; Service de pneumologie, hôpital Cochin, AP-HP, 27, rue du Faubourg Saint-Jacques, 75014 Paris, France
| | - G Chassagnon
- Université Paris Descartes, Sorbonne Paris cité, 75006 Paris, France; Service d'imagerie médicale, hôpital Cochin, AP-HP, 75014 Paris, France
| | - P-R Burgel
- Université Paris Descartes, Sorbonne Paris cité, 75006 Paris, France; Service de pneumologie, hôpital Cochin, AP-HP, 27, rue du Faubourg Saint-Jacques, 75014 Paris, France.
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Putman MS, Simoneau T, Feldman HA, Haagensen A, Boyer D. Low bone density and fractures before and after pediatric lung transplantation. Bone 2018; 111:129-134. [PMID: 29596964 PMCID: PMC5931383 DOI: 10.1016/j.bone.2018.03.021] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/08/2017] [Revised: 02/26/2018] [Accepted: 03/26/2018] [Indexed: 11/17/2022]
Abstract
INTRODUCTION Children undergoing lung transplant are at risk for low bone mineral density (BMD) and fractures. The effect of lung transplantation on bone health in pediatric patients is unknown. MATERIALS AND METHODS We performed a retrospective chart review of all patients ages 2-21 years who underwent lung transplantation at our hospital from January 2000 to January 2015. RESULTS 51 patients were studied. At the time of transplant evaluation, BMD Z-score was -2.2 ± 1.4, and 59% of patients had low BMD. BMD Z-score declined in the first year after treatment and returned to near-baseline by the third post-transplant year. Fractures occurred in 9 patients (18%) before and 15 patients (29%) after transplant. Bisphosphonate use was associated with improvement in BMD Z-score and lower mortality risk. CONCLUSIONS Pediatric patients had a high prevalence of low BMD at the time of lung transplant evaluation. BMD Z-scores declined in the year after transplant and returned to the pre-transplant level by the third post-transplant year while remaining below normal levels. Fractures were common at sites associated with significant morbidity. These findings support efforts to optimize bone health before and after pediatric lung transplantation, and future studies are needed to evaluate the role of bisphosphonates in these patients.
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Affiliation(s)
- Melissa S Putman
- Division of Endocrinology, Boston Children's Hospital, Boston, MA, United States; Endocrine Unit, Massachusetts General Hospital, Boston, MA, United States.
| | - Tregony Simoneau
- Department of Pulmonary Medicine, Connecticut Children's Medical Center, Hartford, CT, United States
| | - Henry A Feldman
- Clinical Research Center, Boston Children's Hospital, Boston, MA, United States
| | - Alexandra Haagensen
- Division of Endocrinology, Boston Children's Hospital, Boston, MA, United States
| | - Debra Boyer
- Division of Respiratory Diseases, Boston Children's Hospital, Boston, MA, United States
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20
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Jardel S, Reynaud Q, Durieu I. Long-term extrapulmonary comorbidities after lung transplantation in cystic fibrosis: Update of specificities. Clin Transplant 2018; 32:e13269. [DOI: 10.1111/ctr.13269] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 04/19/2018] [Indexed: 12/12/2022]
Affiliation(s)
- Sabine Jardel
- Department of Internal Medicine, Adult Cystic Fibrosis Care Center; Hospices Civils de Lyon; Lyon France
- EA HESPER 7425; Université Claude Bernard Lyon 1; Lyon France
| | - Quitterie Reynaud
- Department of Internal Medicine, Adult Cystic Fibrosis Care Center; Hospices Civils de Lyon; Lyon France
- EA HESPER 7425; Université Claude Bernard Lyon 1; Lyon France
| | - Isabelle Durieu
- Department of Internal Medicine, Adult Cystic Fibrosis Care Center; Hospices Civils de Lyon; Lyon France
- EA HESPER 7425; Université Claude Bernard Lyon 1; Lyon France
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Andrés Peiró JV, Granell JB, Moret MF, Galdó AM. Correction of Spinal Deformity on a Lung Transplantation Recipient. Spine Deform 2017; 5:72-76. [PMID: 28038697 DOI: 10.1016/j.jspd.2016.10.001] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/08/2016] [Revised: 09/27/2016] [Accepted: 10/04/2016] [Indexed: 11/17/2022]
Abstract
BACKGROUND The coexistence of lung disease and scoliosis entails a dramatic situation. There are no papers reporting scoliosis surgery in patients who suffered lung transplantation. PURPOSE To describe the case of a patient who underwent surgery to correct progressive spinal deformity after two consecutive lung transplants. STUDY DESIGN Case report, including review of patient records, imaging and pulmonary function tests, and literature review. METHODS A 9-year-old woman diagnosed of idiopathic pulmonary fibrosis and progressive scoliosis underwent lung transplant. Retransplantation of right lung was performed at the age of 14 due to chronic rejection. When she was 16, respiratory function was stable and spinal deformity severely impaired her quality of life. Patient and family demanded a surgical correction. At that moment, she had severe osteoporosis and immunosuppression as a result of anti-rejection therapy. The pattern was a severe double thoracic curve T1-T6 89° and T7-L1 139°. To correct it, a posterior instrumented spine fusion from T2 to L4 using a hybrid configuration was performed. RESULTS No significant complications occurred in perioperative, postoperative, and midterm follow-up periods. Solid fusion was achieved and patient was satisfied with surgery. Unfortunately, chronic lung graft rejection worsened her long-term general status. CONCLUSIONS Scoliosis surgery on lung transplant recipients is feasible, regardless of potential complications related to immunosuppression and osteoporosis. The goal is to improve quality of life.
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Affiliation(s)
- José Vicente Andrés Peiró
- Department of Orthopedic Surgery, Hospital Universitari Vall d'Hebron, Passeig de la Vall d'Hebron 119-129, 08035 Barcelona, Spain.
| | - Joan Bagó Granell
- Department of Orthopedic Surgery, Hospital Universitari Vall d'Hebron, Passeig de la Vall d'Hebron 119-129, 08035 Barcelona, Spain
| | - Montserrat Feliu Moret
- Department of Anesthesiology, Hospital Universitari Vall d'Hebron, Passeig de la Vall d'Hebron 119-129, 08035 Barcelona, Spain
| | - Antonio Moreno Galdó
- Department of Pediatrics, Hospital Universitari Vall d'Hebron, Passeig de la Vall d'Hebron 119-129, 08035 Barcelona, Spain
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Kochetkova EA, Nevzorova VA, Ugai LG, Maistrovskaia YV, Massard G. The Role of Tumor Necrosis Factor Alpha and TNF Superfamily Members in Bone Damage in Patients with End-Stage Chronic Obstructive Lung Disease Prior to Lung Transplantation. Calcif Tissue Int 2016; 99:578-587. [PMID: 27501819 DOI: 10.1007/s00223-016-0185-8] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/31/2016] [Accepted: 08/01/2016] [Indexed: 11/25/2022]
Abstract
A disequilibrium of tumor necrosis superfamily (TNF) members, including the serum osteoprotegerin, soluble receptor activator of nuclear factor-κB ligand, soluble TNF-related apoptosis-inducing ligand and TNF-α, was associated with the occurrence of a reduced skeletal mass and osteoporosis in male patients with end-stage chronic obstructive pulmonary disease (COPD). The purpose of this study was to explore the associations between serum biomarkers of tumor necrosis factor (TNF) superfamily and body and bone compositions in end-stage COPD males. Pulmonary function, T-score at the lumbar spine and femoral neck, lean mass, serum osteoprotegerin (OPG), soluble receptor activator of nuclear factor-κB ligand (sRANKL), TNF-α and its receptors (sTNFR-I, sTNFR-II) and soluble TNF-related apoptosis-inducing ligand (sTRAIL) levels were evaluated in 48 male patients with end-stage COPD and 36 healthy male volunteers. OPG was lower in male COPD patients than in control subjects, whereas sRANKL, TNF-α and its receptors were higher. The serum sTRAIL level showed a tendency to increase compared with that of healthy subjects (P = 0.062). Serum OPG showed a positive correlation with bone density. In contrast, serum TNF-α, sRANKL and sTRAIL were inversely associated with pretransplant bone density. We have noted the appearance of statistically significant inverse relationships between lean mass values and TNF-α, sTNFR-I and II and sRANKL levels in male COPD patients. Moreover, there was a negative correlation between sTRAIL levels with airway obstruction (P = 0.005) and hypercapnia (P = 0.042) in advanced COPD patients. Through a multiple linear regression analysis, our study revealed that a disequilibrium of TNF family members was strongly associated with the occurrence of a reduced skeletal mass and osteoporosis. These results provide further evidence that abnormal levels of TNF superfamily molecules may cause not only a decrease in BMD, but also lower muscle mass in end-stage COPD.
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Affiliation(s)
- Evgenia A Kochetkova
- Central Scientific Research Laboratory, Pacific State Medical University, 2 Ostryakova Av., Vladivostok, Russian Federation, 690950.
| | - Vera A Nevzorova
- Central Scientific Research Laboratory, Pacific State Medical University, 2 Ostryakova Av., Vladivostok, Russian Federation, 690950
| | - Ludmila G Ugai
- Central Scientific Research Laboratory, Pacific State Medical University, 2 Ostryakova Av., Vladivostok, Russian Federation, 690950
| | - Yulia V Maistrovskaia
- Central Scientific Research Laboratory, Pacific State Medical University, 2 Ostryakova Av., Vladivostok, Russian Federation, 690950
| | - Gilbert Massard
- Department of Pulmonology, Allergy and Thoracic Surgery, Faculty of Medicine, University of Strasbourg, Strasbourg, France
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Schmitt JW, Benden C, Dora C, Werner CML. Is total hip arthroplasty safely performed in lung transplant patients? Current experience from a retrospective study of the Zurich lung transplant cohort. Patient Saf Surg 2016; 10:17. [PMID: 27429648 PMCID: PMC4946112 DOI: 10.1186/s13037-016-0105-x] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/14/2016] [Accepted: 06/30/2016] [Indexed: 11/23/2022] Open
Abstract
Background In recent years, the number of lung transplants has increased rapidly, with higher quality of life and improved survival rates in transplant recipients, including patients with advanced age. This, in turn, means that more transplant recipients will seek musculoskeletal care to treat degenerative joint disease and also trauma incidents. Safety concerns regarding elective and posttraumatic hip arthroplasty in transplant patients include an increased risk of infection, wound healing problems, periprosthetic fractures and loosening of the implants. Methods Clinical outcomes and safety aspects were retrospectively reviewed for five primary total hip arthroplasties (THA) in lung transplant recipients with minimal follow-up of two years at average of 2.6 (2–11) years. Patients were recruited from the Zurich Lung Transplant Center comprising of a cohort of 253 patients between January 1st, 2004 and December 31st, 2013. Results All five patients subjectively reported excellent outcomes after THA with a final average Harris Hip Score of 97 (86–100). One 71-year-old patient died 26 months after THA unrelated to arthroplasty. One superficial wound healing disturbance was documented. No periprosthetic fractures, no dislocations, no periprosthetic infections, no further revision surgery, no implant loosening was observed. Conclusions In conclusion, THA can be safely and successfully performed even in lung transplant patients under long-term immunosuppressive therapy and polymedication, provided a multidisciplinary approach can be granted.
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Affiliation(s)
- Jürgen W Schmitt
- Department of Trauma Surgery, University Hospital Zurich, CH-8091 Zurich, Switzerland ; Department of Pulmonology, University Hospital Zurich, CH-8091 Zurich, Switzerland
| | - Christian Benden
- Division of Pulmonary Medicine, University Hospital Zurich, CH-8091 Zurich, Switzerland
| | - Claudio Dora
- Department of Orthopaedics, Balgrist University Hospital, Forchstrasse 340, CH-8008 Zurich, Switzerland
| | - Clément M L Werner
- Department of Trauma Surgery, University Hospital Zurich, CH-8091 Zurich, Switzerland
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Balci M, Ari E, Vayvada M, Salturk C, Asicioglu E, Yeginsu A, Kutlu C. Osteoporosis in Lung Transplantation Candidates: Association With 6-minute Walking Test and Body Mass Index. Transplant Proc 2016; 48:2147-51. [DOI: 10.1016/j.transproceed.2016.02.074] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/18/2015] [Revised: 02/06/2016] [Accepted: 02/24/2016] [Indexed: 10/21/2022]
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Abstract
PURPOSE OF REVIEW Mineral and bone disorders are common problems in organ transplant recipients. Successful transplantation solves many aspects of abnormal mineral and bone metabolism, but the degree of improvement is frequently incomplete. Posttransplant bone disease can affect long-term outcomes as well as increase the likelihood of fracture. In this article, we reviewed the major posttransplant bone diseases and recent advances in treatment strategies. RECENT FINDINGS Pretransplant bone disease and immunosuppressants are important risk factors for posttransplant bone disease. Corticosteroid withdrawal may result in minimal or no protection against fractures, with increased risk for acute rejection. Vitamin D analogue and bisphosphonate are frequently used to prevent and treat posttransplant osteoporosis. Posttransplant hyperparathyroidism increases the risk for all-cause mortality and graft loss, but not major cardiovascular events. Cinacalcet was well tolerated and effectively controlled hypercalcemic hyperparathyroidism; however, it did not improve bone mineral density and discontinuation led to parathyroid hormone rebound. Six-month paricalcitol supplementation reduced parathyroid hormone levels and attenuated bone remodeling and mineral loss in case of posttransplant hyperparathyroidism. SUMMARY Posttransplant bone diseases present in various forms, including osteoporosis, hyperparathyroidism, adynamic bone disease, and osteonecrosis. Prophylactic and therapeutic approaches to both pretransplant and posttransplant periods should be considered.
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Affiliation(s)
- Hee Jung Jeon
- aDepartment of Internal Medicine, Hallym University Kangdong Sacred Heart Hospital, Seoul, Republic of Korea bDivision of Nephrology, Department of Internal Medicine, Asan Medical Center, University of Ulsan College of Medicine, Seoul, Republic of Korea cTransplantation Center, Seoul National University Hospital, Seoul, Republic of Korea *Hee Jung Jeon and Hyosang Kim contributed equally to the writing of this article
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Budev MM, Yun JJ. Medical complications after lung transplantation. CURRENT PULMONOLOGY REPORTS 2015. [DOI: 10.1007/s13665-015-0115-7] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/23/2022]
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Lynch JP, Sayah DM, Belperio JA, Weigt SS. Lung transplantation for cystic fibrosis: results, indications, complications, and controversies. Semin Respir Crit Care Med 2015; 36:299-320. [PMID: 25826595 DOI: 10.1055/s-0035-1547347] [Citation(s) in RCA: 45] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/08/2023]
Abstract
Survival in patients with cystic fibrosis (CF) has improved dramatically over the past 30 to 40 years, with mean survival now approximately 40 years. Nonetheless, progressive respiratory insufficiency remains the major cause of mortality in CF patients, and lung transplantation (LT) is eventually required. Timing of listing for LT is critical, because up to 25 to 41% of CF patients have died while awaiting LT. Globally, approximately 16.4% of lung transplants are performed in adults with CF. Survival rates for LT recipients with CF are superior to other indications, yet LT is associated with substantial morbidity and mortality (∼50% at 5-year survival rates). Myriad complications of LT include allograft failure (acute or chronic), opportunistic infections, and complications of chronic immunosuppressive medications (including malignancy). Determining which patients are candidates for LT is difficult, and survival benefit remains uncertain. In this review, we discuss when LT should be considered, criteria for identifying candidates, contraindications to LT, results post-LT, and specific complications that may be associated with LT. Infectious complications that may complicate CF (particularly Burkholderia cepacia spp., opportunistic fungi, and nontuberculous mycobacteria) are discussed.
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Affiliation(s)
- Joseph P Lynch
- Division of Pulmonary, Critical Care Medicine, Clinical Immunology and Allergy, Department of Internal Medicine, The David Geffen School of Medicine at UCLA, Los Angeles, California
| | - David M Sayah
- Division of Pulmonary, Critical Care Medicine, Clinical Immunology and Allergy, Department of Internal Medicine, The David Geffen School of Medicine at UCLA, Los Angeles, California
| | - John A Belperio
- Division of Pulmonary, Critical Care Medicine, Clinical Immunology and Allergy, Department of Internal Medicine, The David Geffen School of Medicine at UCLA, Los Angeles, California
| | - S Sam Weigt
- Division of Pulmonary, Critical Care Medicine, Clinical Immunology and Allergy, Department of Internal Medicine, The David Geffen School of Medicine at UCLA, Los Angeles, California
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Pundole XN, Barbo AG, Lin H, Champlin RE, Lu H. Increased incidence of fractures in recipients of hematopoietic stem-cell transplantation. J Clin Oncol 2015; 33:1364-70. [PMID: 25779562 DOI: 10.1200/jco.2014.57.8195] [Citation(s) in RCA: 40] [Impact Index Per Article: 4.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/20/2022] Open
Abstract
PURPOSE The number of long-term survivors after hematopoietic stem-cell transplantation (HSCT) for malignant and nonmalignant disorders is increasing, and late effects are gaining importance. Osteoporosis and fractures can worsen the quality of life of HSCT survivors, but the burden of the disease is unknown. PATIENTS AND METHODS We conducted a retrospective study of patients older than age 18 years who underwent an HSCT at The University of Texas MD Anderson Cancer Center from January 1, 1997, to December 31, 2011, and were observed until December 31, 2013, to ascertain occurrence of fractures. Cumulative incidence rates of fractures were calculated with death as a competing risk. Age- and sex-specific incidence rates per person-year of fracture were compared with those of the US general population by using estimated rates from the 1994 National Health Interview Survey and the 2004 National Hospital Discharge Survey. RESULTS A total of 7,620 patients underwent an HSCT from 1997 to 2011 at the MD Anderson Cancer Center of whom 602 (8%) developed a fracture. Age, underlying disease, and HSCT type were significantly associated with fracture. Age- and sex-specific fracture incidence rates after HSCT were significantly greater than those of the US general population in almost all subgroups. The striking difference was an approximately eight times greater risk in females and approximately seven to nine times greater risk in males age 45 to 64 years old when compared with the National Health Interview Survey and National Hospital Discharge Survey fracture rates. CONCLUSION The incidence of fractures is compellingly higher after HSCT.
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Affiliation(s)
- Xerxes N Pundole
- All authors: The University of Texas MD Anderson Cancer Center, Houston, TX
| | - Andrea G Barbo
- All authors: The University of Texas MD Anderson Cancer Center, Houston, TX
| | - Heather Lin
- All authors: The University of Texas MD Anderson Cancer Center, Houston, TX
| | - Richard E Champlin
- All authors: The University of Texas MD Anderson Cancer Center, Houston, TX
| | - Huifang Lu
- All authors: The University of Texas MD Anderson Cancer Center, Houston, TX.
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Spahr JE, West SC. Heart-lung transplantation: pediatric indications and outcomes. J Thorac Dis 2014; 6:1129-37. [PMID: 25132980 DOI: 10.3978/j.issn.2072-1439.2014.07.05] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Key Words] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/21/2014] [Accepted: 06/23/2014] [Indexed: 11/14/2022]
Abstract
As indications for heart-lung transplant (HLT) have changed to some degree in the past 30 years, this treatment is being used less frequently in children due to more advanced care of severe heart and lung disease. This is fortunate as the outcomes for HLT are poor compared to other solid organ transplants and this is mainly due to the poorer outcome of the lung graft.
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Affiliation(s)
- Jonathan E Spahr
- Children's Hospital of Pittsburgh of UPMC, Pittsburgh, PA 15224, USA ; University of Pittsburgh School of Medicine, Pittsburgh, PA 15224, USA
| | - Shawn C West
- Children's Hospital of Pittsburgh of UPMC, Pittsburgh, PA 15224, USA ; University of Pittsburgh School of Medicine, Pittsburgh, PA 15224, USA
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Kulak CAM, Borba VZC, Kulak Júnior J, Custódio MR. Bone disease after transplantation: osteoporosis and fractures risk. ACTA ACUST UNITED AC 2014; 58:484-92. [DOI: 10.1590/0004-2730000003343] [Citation(s) in RCA: 26] [Impact Index Per Article: 2.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/09/2014] [Accepted: 05/28/2014] [Indexed: 01/16/2023]
Abstract
Organ transplantation is the gold standard therapy for several end-stage diseases. Bone loss is a common complication that occurs in transplant recipients. Osteoporosis and fragility fractures are serious complication, mainly in the first year post transplantation. Many factors contribute to the pathogenesis of bone disease following organ transplantation. This review address the mechanisms of bone loss including the contribution of the immunosuppressive agents as well as the specific features to bone loss after kidney, lung, liver, cardiac and bone marrow transplantation. Prevention and management of bone loss in the transplant recipient should be included in their post transplant follow-up in order to prevent fractures.
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Vanacor R, Raimundo FV, Marcondes NA, Corte BP, Ascoli AM, Azambuja AZD, Scopel L, Santos PVD, Dalcin PTR, Faulhaber GAM, Furlanetto TW. Prevalence of low bone mineral density in adolescents and adults with cystic fibrosis. Rev Assoc Med Bras (1992) 2014; 60:53-8. [PMID: 24918853 DOI: 10.1590/1806-9282.60.01.012] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/25/2013] [Accepted: 07/01/2013] [Indexed: 11/22/2022] Open
Abstract
OBJECTIVE The aim of this cross-sectional study was to evaluate the prevalence of low bone mass density in cystic fibrosis patients as well as to evaluate the factors associated with bone mass in such patients. METHODS Bone mass density was measured by dual-photon X-ray absorptiometry of lumbar spine (L1-L4), in patients ≤19 years old, or lumbar spine and femur (total and neck) in patients ≥20 years old. Evaluations of nutritional status, biochemical parameters, and lung function were performed. Medication data were obtained from medical records. RESULTS Fifty-eight patients were included in the study (25 males/ 33 females), mean age 23.9 years (16-53 years). The prevalence of bone mass below the expected range for age at any site was 20.7%. None of the subjects had history of fracture. Lumbar spine Z-score in cystic fibrosis patients correlated positively with body mass index (r= 0.3, p=0.001), and forced expiratory volume in the first second (% predicted) (r=0.415, p=0.022). Mean lumbar spine Z-score was higher in women (p=0.001), in patients with no pancreatic insufficiency (p=0.032), and in patients with no hospitalization in the last 3 months (p=0.02). After multivariate analysis, body mass index (p= 0.001) and sex (p=0.001) were independently associated with Z-score in lumbar spine. CONCLUSION Low bone mass is a frequent problem in patients with CF, being independently associated with body mass index, and male sex.
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Affiliation(s)
- Roberta Vanacor
- Postgraduate Program, Medicine, Medical Sciences, Federal University of Rio Grande do Sul, Porto Alegre, RS, Brazil
| | - Fabiana V Raimundo
- Postgraduate Program, Medicine, Medical Sciences, Federal University of Rio Grande do Sul, Porto Alegre, RS, Brazil
| | - Natália A Marcondes
- Postgraduate Program, Medicine, Medical Sciences, Federal University of Rio Grande do Sul, Porto Alegre, RS, Brazil
| | - Bruno P Corte
- Division of Internal Medicine, Hospital de Clínicas de Porto Alegre, Federal University of Rio Grande do Sul, Porto Alegre, RS, Brazil
| | - Aline M Ascoli
- Division of Internal Medicine, Hospital de Clínicas de Porto Alegre, Federal University of Rio Grande do Sul, Porto Alegre, RS, Brazil
| | - Aline Z de Azambuja
- Division of Internal Medicine, Hospital de Clínicas de Porto Alegre, Federal University of Rio Grande do Sul, Porto Alegre, RS, Brazil
| | - Luciano Scopel
- Division of Internal Medicine, Hospital de Clínicas de Porto Alegre, Federal University of Rio Grande do Sul, Porto Alegre, RS, Brazil
| | - Patrícia V Dos Santos
- Division of Internal Medicine, Hospital de Clínicas de Porto Alegre, Federal University of Rio Grande do Sul, Porto Alegre, RS, Brazil
| | - Paulo T R Dalcin
- Division of Pneumology, Hospital de Clínicas de Porto Alegre, Federal University of Rio Grande do Sul, Porto Alegre, RS, Brazil
| | - Gustavo A M Faulhaber
- Division of Internal Medicine, Hospital de Clínicas de Porto Alegre, Federal University of Rio Grande do Sul, Porto Alegre, RS, Brazil
| | - Tânia W Furlanetto
- Division of Internal Medicine, Hospital de Clínicas de Porto Alegre, Federal University of Rio Grande do Sul, Porto Alegre, RS, Brazil
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Picard C, Boisseau M, De Miranda S, Hamid A, Grenet D, Parquin F, Sage E, Stern M, Roux A. [The management of lung transplantation candidates. A case series]. Rev Mal Respir 2014; 32:1-7. [PMID: 25618198 DOI: 10.1016/j.rmr.2014.02.007] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/28/2013] [Accepted: 12/09/2013] [Indexed: 12/15/2022]
Abstract
INTRODUCTION Lung transplantation (LT) is associated with an increased risk of infection, cancer, chronic renal failure, cardiovascular disease and osteoporosis. Some risk factors precede transplantation and could benefit for early diagnosis and optimised care. METHODS The incidence of comorbidities and their treatment before referral were assessed in 157 consecutive lung transplant candidates between 2008 and 2011. RESULTS The median age was 37years [25; 51]. Fifty-six percent had a body mass index below 19kg/m(2). In the COPD group, only 50 % had undergone a pulmonary rehabilitation program in the preceding 2 years. Osteoporosis was present in 42 %, of whom 36 % were on bisphophonate therapy. Vitamin D deficiency was present in 65 %. Previously undiagnosed cardiovascular risk factors were discovered during LT assessment: hypertension in one patient, hypercholesterolemia in 6 % and diabetes in 4 %. Poor dental condition necessitating extractions were found in 41 % of patients. Protective anti-HBs antibodies levels were present in 50 % of the patients at the time of referral. CONCLUSION The assessment and early treatment of nutritional disorders, osteoporosis and risk factors for infection as well as addressing associated cardiovascular risk factors should be optimised in the care of patients with chronic respiratory insufficiency. The potential for becoming a lung transplant candidate in the future should be kept in mind early in the global management of those patients.
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Affiliation(s)
- C Picard
- Service de pneumologie, hôpital Foch, groupe de transplantation pulmonaire, 40, rue Worth, 92150 Suresnes, France.
| | - M Boisseau
- Service de pneumologie, hôpital Foch, groupe de transplantation pulmonaire, 40, rue Worth, 92150 Suresnes, France
| | - S De Miranda
- Service de pneumologie, hôpital Foch, groupe de transplantation pulmonaire, 40, rue Worth, 92150 Suresnes, France
| | - A Hamid
- Service de pneumologie, hôpital Foch, groupe de transplantation pulmonaire, 40, rue Worth, 92150 Suresnes, France
| | - D Grenet
- Service de pneumologie, hôpital Foch, groupe de transplantation pulmonaire, 40, rue Worth, 92150 Suresnes, France
| | - F Parquin
- Unité de soins intensifs respiratoires, service de chirurgie thoracique, hôpital Foch, groupe de transplantation pulmonaire, 92150 Suresnes, France
| | - E Sage
- Unité de soins intensifs respiratoires, service de chirurgie thoracique, hôpital Foch, groupe de transplantation pulmonaire, 92150 Suresnes, France
| | - M Stern
- Service de pneumologie, hôpital Foch, groupe de transplantation pulmonaire, 40, rue Worth, 92150 Suresnes, France
| | - A Roux
- Service de pneumologie, hôpital Foch, groupe de transplantation pulmonaire, 40, rue Worth, 92150 Suresnes, France
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Incidence of fractures after cardiac and lung transplantation: a single center experience. J Osteoporos 2014; 2014:573041. [PMID: 24864223 PMCID: PMC4016909 DOI: 10.1155/2014/573041] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/20/2013] [Revised: 03/17/2014] [Accepted: 03/19/2014] [Indexed: 11/24/2022] Open
Abstract
Osteoporotic fractures are well-known complications of organ transplantation. Fracture rates up to 35% have been previously reported following heart and lung transplantations. Our institutional pretransplant protocols include DXA scans, vitamin D screening, and appropriate antiresorptive therapy. We aimed to assess the incidence of fragility fractures following cardiac or lung transplantation. In a retrospective study 210 electronic medical records of patients who underwent LT (110 men, 100 women) and 105 HT (88 men, 17 women) between 2005 and 2010 were analyzed. Both clinical and radiographic fractures were recorded. DXA scans were obtained immediately after transplant. 17 out of 210 LT patients (8.0%) had fractures after transplantation and 9 out of 105 HT patients (8.6%) had fractures. The median time to the first fracture was 12 months and the mean time was 18 months for both LT and HT. In the HT recipients, the median femoral neck T score was statistically lower in the fracture group versus the nonfracture group. Similar results were seen in the LT patients. Conclusion. Our findings demonstrate a much lower incidence of fractures in heart and lung transplant recipients in comparison with earlier reports. Comprehensive bone care and early initiation of antiresorptive therapy are possible contributors to these improved outcomes.
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Bone density in heart or lung transplant recipients--a longitudinal study. Transplant Proc 2013; 45:2357-65. [PMID: 23747143 DOI: 10.1016/j.transproceed.2012.09.117] [Citation(s) in RCA: 31] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/30/2012] [Accepted: 09/18/2012] [Indexed: 01/27/2023]
Abstract
BACKGROUND Osteoporosis is prevalent among heart or lung transplant (HLT) candidates. Bone loss is common posttransplant, with an associated increase in fracture risk. There is a lack of consensus regarding optimal management of bone health in HLT recipients. We report bone health data in a cohort of HLT recipients before and after transplantation and make recommendations for management. METHODS Patients over the age of 20 who had a heart or lung transplant between 2000 and 2011 were identified from the New Zealand HLT Service database, and demographic data, immunosuppressive regimens, bisphosphonate use, and serial bone mineral density (BMD) data were extracted. RESULTS Pretransplant BMD was available in 52 heart and 72 lung transplant recipients; 30 and 42, respectively, also had posttransplant BMD data. Pretransplant osteopenia or osteoporosis prevalence were 23% and 8% for heart candidates and 36% and 31% for lung candidates. Posttransplant, BMD decreased significantly at the femoral neck but not at the lumbar spine in the first year, with subsequent stabilization particularly in the presence of bisphosphonate use. Pretransplant BMD was the major predictor for developing osteopenia or osteoporosis after transplantation. CONCLUSION A significant proportion of HLT recipients have osteopenia or osteoporosis pretransplant, and this persists posttransplant. Pretransplant BMD is an important predictor of subsequent osteopenia or osteoporosis development, allowing risk stratification and targeted intervention.
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Neuringer IP, Noone P, Cicale RK, Davis K, Aris RM. Managing complications following lung transplantation. Expert Rev Respir Med 2012; 3:403-23. [PMID: 20477331 DOI: 10.1586/ers.09.27] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/04/2023]
Abstract
Lung transplantation has become a proven therapeutic option for patients with end-stage lung disease, extending life and providing improved quality of life to those who otherwise would continue to be breathless and oxygen-dependent. Over the past 20 years, considerable experience has been gained in understanding the multitude of medical and surgical issues that impact upon patient survival. Today, clinicians have an armamentarium of tools to manage diverse problems such as primary graft dysfunction, acute and chronic allograft rejection, airway anastomotic issues, infectious complications, renal dysfunction, diabetes and osteoporosis, hematological and gastrointestinal problems, malignancy, and other unique issues that confront immunosuppressed solid organ transplant recipients.
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Affiliation(s)
- Isabel P Neuringer
- Division of Pulmonary and Critical Care Medicine and the Cystic Fibrosis/Pulmonary Research and Treatment Center, The University of North Carolina at Chapel Hill, Chapel Hill, NC 27599-7524, USA.
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Abstract
OBJECTIVE Decreased bone mineral density has been found in the advanced stages of various lung diseases. Limited data are available about prevalence and risk factors for osteoporosis/osteopenia (OP) in pulmonary arterial hypertension (PAH). METHODS Patients with PAH (either idiopathic or secondary to scleroderma [SSC-PAH]) who underwent bone density testing for lung transplant evaluation were included. Results of bone density testing, demographic data, pulmonary function testing, hemodynamic measures, and 6-minute walk distance test (6MWD) were collected. RESULTS Thirty-two patients were identified (27 women/5 men, 24 idiopathic PAH/8 SSC-PAH) and OP was found in 22 (69%) patients. Patients with SSC-PAH had more significant indications of OP at all of the measured sites. The OP group had lower FEV1 (P = 0.01) and a significantly lower 6MWD (P = 0.04) as compared with patients with PAH with normal bone density. Hemodynamics indicated no statistically significant differences between the groups other than a lower mean pulmonary artery pressure (P = 0.01) in the OP group. Patients with a history of corticosteroid use and smoking, postmenopausal status, decreased functional capacity (as measured by poor New York Heart Association functional class and 6MWD), SSC-PAH, and need for oxygen during a 6MWD test had an increased risk of OP by univariate logistic regression. CONCLUSIONS Reduced bone density can be seen in a majority of patients with advanced PAH. Risk factors for reduced bone density include SSC-PAH, reduced 6MWD, need for oxygen during 6MWD testing, reduced FEV1, a history of smoking or corticosteroid use, and postmenopausal status.
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Abstract
Transplantation is an established therapy for end-stage diseases of kidney, lung, liver, and heart among others. Osteoporosis and fragility fractures are serious complications of organ transplantation, particularly in the first post-transplant year. Many factors contribute to the pathogenesis of osteoporosis following organ transplantation. This review addresses the mechanisms of bone loss that occurs both in the early and late post-transplant periods, including the contribution of the immunosuppressive agents as well as the specific features to bone loss after kidney, lung, liver, cardiac, and bone marrow transplantation. Prevention and treatment for osteoporosis in the transplant recipient are also discussed.
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Affiliation(s)
- Carolina A Moreira Kulak
- Division of Endocrinology & Metabolism of Hospital de Clínicas-SEMPR, Federal University of Parana, Av. Agostinho Leão Júnior 285, Alto da Glória, Curitiba, Paraná, Cep: 80030-013, Brazil.
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Stein EM, Ortiz D, Jin Z, McMahon DJ, Shane E. Prevention of fractures after solid organ transplantation: a meta-analysis. J Clin Endocrinol Metab 2011; 96:3457-65. [PMID: 21849532 PMCID: PMC3205901 DOI: 10.1210/jc.2011-1448] [Citation(s) in RCA: 57] [Impact Index Per Article: 4.4] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/19/2022]
Abstract
CONTEXT Bone loss and fracture are serious sequelae of organ transplantation, particularly in the first posttransplant year. Most interventional studies have been inadequately powered to detect effects on fracture. OBJECTIVE The objective of the study was to determine whether treatment with bisphosphonates (BP) or active vitamin D analogs (vitD) during the first year after transplantation reduces fracture risk and estimate the effect of these interventions on bone loss. DATA SOURCES Sources included PUBMED, MEDLINE, Cochrane Library, and abstracts from scientific meetings (presented 2003-2010). STUDY SELECTION Randomized controlled clinical trials of BP or vitD in solid organ transplant recipients were included if treatment was initiated at the time of transplantation and fracture data were collected. DATA EXTRACTION Two investigators independently extracted data and rated study quality. Fixed effect and random-effects models were used to obtain pooled estimates. DATA SYNTHESIS Eleven studies of 780 transplant recipients (134 fractures) were included. Treatment with BP or vitD reduced the number of subjects with fracture [odds ratio (OR) 0.50 (0.29, 0.83)] and number of vertebral fractures, [OR 0.24 (0.07, 0.78)]. An increase in bone mineral density at the lumbar spine [2.98% (1.31, 4.64)] and femoral neck [3.05% (2.16, 3.93)] was found with treatment. When BP trials (nine studies, 625 subjects) were examined separately, there was a reduction in number of subjects with fractures [OR 0.53 (0.30, 0.91)] but no significant reduction in vertebral fractures [OR 0.34 (0.09, 1.24)]. CONCLUSIONS Treatment with BP or vitD during the first year after solid organ transplant was associated with a reduction in the number of subjects with fractures and fewer vertebral fractures.
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Affiliation(s)
- Emily M Stein
- Division of Endocrinology, Department of Medicine, Columbia University College of Physicians and Surgeons, New York, New York 10032, USA
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Post-transplantation osteoporosis. ACTA ACUST UNITED AC 2011; 54:143-9. [PMID: 20485902 DOI: 10.1590/s0004-27302010000200009] [Citation(s) in RCA: 22] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/03/2009] [Accepted: 02/09/2010] [Indexed: 11/22/2022]
Abstract
Transplantation is an established therapy for many hematologic disorders as well as for end-stage diseases of the kidney, lung, liver, heart among others. Osteoporosis and a high incidence of fragility fractures have emerged as a complication of organ transplantation. Many factors contribute to the pathogenesis of osteoporosis following organ transplantation. In addition, most patients have some form of bone disease prior to transplantation, which is usually related to adverse effects of end-stage organ failure on the skeleton. This chapter reviews the mechanisms of bone loss that occur both in the early and late post-transplant periods including the contribution of immunosuppressive agents as well as the specific features of bone loss after kidney, lung, liver, cardiac and bone marrow transplantation. Prevention and treatment for osteoporosis in the transplant recipient will also be addressed.
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40
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Raef H, Al-Bugami M, Balharith S, Moawad M, El-Shaker M, Hassan A, Al-Shaikh A, Al-Badawi I. Updated recommendations for the diagnosis and management of osteoporosis: a local perspective. Ann Saudi Med 2011; 31:111-28. [PMID: 21403406 PMCID: PMC3102469 DOI: 10.4103/0256-4947.77502] [Citation(s) in RCA: 17] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/06/2023] Open
Abstract
Postmenopausal osteoporosis and osteoporosis in elderly men are major health problems, with a significant medical and economic burden. Although osteopenia and osteoporosis are more common locally than in the West, fracture rates are generally less than in Western countries. Vitamin D deficiency is common in the region and contributes adversely to bone health. Vitamin D deficiency should be suspected and treated in all subjects with ostopenia or osteoporosis. The use of risk factors to determine fracture risk has been adopted by the World Health Organization and many international societies. Absolute fracture risk methodology improves the use of resources by targeting subjects at higher risk of fractures for screening and management. The King Faisal Specialist Hospital Osteoporosis Working Group recommends screening for women 65 years and older and for men 70 years and older. Younger subjects with clinical risk factors and persons with clinical evidence of osteoporosis or diseases leading to osteoporosis should also be screened. These guidelines provide recommendations for treatment for postmenopausal women and men older than 50 years presenting with osteoporotic fractures for persons having osteoporosis-after excluding secondary causes-or for persons having low bone mass and a high risk for fracture. The Working Group has suggested an algorithm to use at King Faisal Specialist Hospital that is based on the availability, cost, and level of evidence of various therapeutic modalities. Adequate calcium and vitamin D supplement are recommended for all. Weekly alendronate (in the absence of contraindications) is recommended as first-line therapy. Alternatives to alendronate are raloxifene or strontium ranelate. Second-line therapies are zoledronic acid intravenously once yearly, when oral therapy is not feasible or complicated by side effects, or teriparatide in established osteoporosis with fractures.
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Affiliation(s)
- Hussein Raef
- Department of Medicine, King Faisal Specialist Hospital and Research Centre, Riyadh, Saudi Arabia.
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Abstract
Objective Osteoporosis may significantly impair the final result of lung transplantation. The purpose of study is to determine the prevalence of osteoporosis with the regard to risk factors for osteoporosis in patients awaiting lung transplantation. Materials and methods We determined bone mineral density (BMD) in 48 patients (12 with idiopathic pulmonary fibrosis (IPF), 15 with other form idiopathic interstitial pneumonia (IIP), 5 with sarcoidosis and 16 with COPD) referred for lung transplantation (LT). BMD was performed on lumbar spine (LS), total hip (TH), and femoral neck (FN). Osteoporosis risk factors were analyzed with the consideration to principal diagnosis, lung function tests (FVC, FEV1) and mobility (6 MWT; six minute walking test). Results In osteoporosis group (50% of study population) the most affected was LS (mean T-score -3 ± 1), with higher steroid consumption (cumulative steroid dose 40 ± 28), lower FVC, FEV1 and mobility (6 MWT: 285 m) than in patients without osteoporosis. COPD patients presented the lowest BMD with the highest cumulative steroid dose (csd/kg: 0.6 ± 0.6), lowest FEV1 (21 ± 15% pred.) and 6 MWT (279 m). In patients with the lowest steroid consumption (IPF) the best results of BMD and FVC, FEV1 and 6 MWT were observed. No relation was found between BMD and sex and age in study group. Conclusions Osteoporosis is very common in patients referred for lung transplantation, especially among COPD candidates. Steroid consumption is the mean risk factor. Therefore, early diagnosis and prevention of osteoporosis in lung transplant candidates should receive high priority.
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Dessables F. La transplantation pulmonaire: avant, pendant et après… — Bénéfices de la transplantation pulmonaire et de la réadaptation. MEDECINE INTENSIVE REANIMATION 2011. [DOI: 10.1007/s13546-010-0216-9] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/01/2022]
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Arenas-de Larriva M, Vaquero-Barrios J, Redel-Montero J, Santos-Luna F. Bone Mineral Density in Lung Transplant Candidates. Transplant Proc 2010; 42:3208-10. [DOI: 10.1016/j.transproceed.2010.05.058] [Citation(s) in RCA: 8] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/30/2022]
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Bone Mineral Density in Patients With Chronic Obstructive Pulmonary Disease Who Are Candidates for Lung Transplant. Transplant Proc 2010; 42:3020-2. [DOI: 10.1016/j.transproceed.2010.07.069] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/18/2022]
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Accelerated Bone Mineral Density Loss Occurs with Similar Incidence and Severity, But with Different Risk Factors, after Autologous versus Allogeneic Hematopoietic Cell Transplantation. Biol Blood Marrow Transplant 2010; 16:1130-7. [DOI: 10.1016/j.bbmt.2010.02.017] [Citation(s) in RCA: 20] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/13/2010] [Accepted: 02/19/2010] [Indexed: 11/22/2022]
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Abstract
Osteoporosis is prevalent in transplant recipients and is related to pre- and post-transplantation factors. Low bone density and fractures may antedate transplantation, related to traditional risk factors for osteoporosis, effects of chronic illness, and end-stage organ failure and its therapy, on the skeleton. Bone loss after transplantation is related to adverse effects of immunosuppressive drugs (glucocorticoids and calcineurin inhibitors) on bone remodeling. Newer immunosuppressive medications may permit lower doses of glucocorticoids and may be associated with decreased bone loss and fractures. Bisphosphonates are currently the most effective agents for the prevention and treatment of post-transplantation osteoporosis.
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Affiliation(s)
- Emily Stein
- Division of Endocrinology, Department of Medicine, College of Physicians & Surgeons, Columbia University, 630 West 168th Street, PH8-864, New York, NY 10032, USA
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Spahr JE, Love RB, Francois M, Radford K, Meyer KC. Lung transplantation for cystic fibrosis: Current concepts and one center's experience. J Cyst Fibros 2007; 6:334-50. [PMID: 17418647 DOI: 10.1016/j.jcf.2006.12.010] [Citation(s) in RCA: 25] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/02/2006] [Revised: 12/14/2006] [Accepted: 12/20/2006] [Indexed: 10/23/2022]
Abstract
BACKGROUND Although new approaches to the treatment of patients with cystic fibrosis (CF) are significantly prolonging their lives, most patients will eventually develop respiratory failure due to progressive bronchiectasis caused by chronic lung infection and inflammation and die from to respiratory failure. We examined our center's (University of Wisconsin Hospital and Clinics) experience with lung transplantation for patients with CF and reviewed the literature to examine current and evolving approaches to transplantation for this indication. METHODS We reviewed all published literature pertaining to lung transplantation for CF through 2006, and we reviewed all aspects of transplantation for patients with CF at our institution from 1994 to 2005. RESULTS Major complications following lung transplantation include acute rejection, bacterial infection, and bronchiolitis obliterans. Five-year survival at UWHC (Kaplan-Meier) is 67%, and survival was not adversely affected by transplanting patients receiving mechanical ventilation. The major cause of death for transplant recipients was bronchiolitis obliterans syndrome (BOS). CONCLUSIONS Lung transplantation for CF is associated with acceptable survival rates and can improve quality of life. Lung transplant should be offered to all patients with advanced CF lung disease if they meet currently accepted inclusion and exclusion criteria.
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Affiliation(s)
- J E Spahr
- University of Wisconsin School of Medicine and Public Health, WI, USA.
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Kulak CAM, Borba VZC, Kulak Júnior J, Shane E. Transplantation osteoporosis. ACTA ACUST UNITED AC 2007; 50:783-92. [PMID: 17117303 DOI: 10.1590/s0004-27302006000400023] [Citation(s) in RCA: 19] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/30/2006] [Accepted: 06/10/2006] [Indexed: 11/21/2022]
Abstract
In the past two decades, there has been a rapid increase in the number of organ transplanted worldwide, including Brazil, along with an improvement in survival and quality of life of the transplant recipients. Osteoporosis and a high incidence of fragility fractures have emerged as a complication of organ transplantation. Many factors contribute to the pathogenesis of osteoporosis following organ transplantation. In addition, most patients have some form of bone disease prior to transplantation, which is usually related to adverse effects of end-stage organ failure on the skeleton. This chapter reviews the mechanisms of bone loss that occur both in the early and late post-transplant periods, as well as the features specific to bone loss after kidney, lung, liver, cardiac and bone marrow transplantation. Prevention and treatment for osteoporosis should be instituted prior and in the early and late phase after transplantation, and will also be addressed in this article.
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Affiliation(s)
- Carolina A M Kulak
- SEMPR, Department of Endocrinology and Metabology, Federal University of Parana, PR, Brazil
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Oto T, Venkatachalam R, Morsi YS, Marasco S, Pick A, Rabinov M, Rosenfeldt F. A reinforced sternal wiring technique for transverse thoracosternotomy closure in bilateral lung transplantation: From biomechanical test to clinical application. J Thorac Cardiovasc Surg 2007; 134:218-24. [PMID: 17599512 DOI: 10.1016/j.jtcvs.2007.03.003] [Citation(s) in RCA: 12] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/28/2006] [Revised: 02/22/2007] [Accepted: 03/08/2007] [Indexed: 11/16/2022]
Abstract
OBJECTIVES A high incidence of failure of transverse thoracosternotomy closure, involving the loops of wire cutting through the sternum, remains a significant morbidity after bilateral lung transplantation. We postulated that placing peristernal wires inside the usual longitudinal wires could prevent the longitudinal wires from cutting through the sternum. The aims of this study were to investigate the biomechanical and clinical efficacy of the proposed reinforced sternal closure technique. METHODS In vitro, 24 artificial sternal models were wired with the reinforced or conventional wiring techniques and were tested either by means of longitudinal distraction or anterior-posterior shear (n = 6 per group). In vivo, the 6-month outcomes of 70 bilateral lung transplantations, including 27 reinforced and 43 conventional wiring techniques, were assessed. RESULTS Reinforced wiring was stronger than conventional wiring for both longitudinal distraction (yield load: 585 +/- 60 vs 334 +/- 21 N [P = .03]; maximum load: 807 +/- 60 vs 525 +/- 34 N [P = .03]; postyield stiffness: 91.0 +/- 22.0 vs 32.8 +/- 11.8 N/mm [P = .04]) and anterior-posterior shear (yield load: 405 +/- 9 vs 364 +/- 16 N [P = .03]; postyield stiffness: 47.4 +/- 6.1 vs 27.5 +/- 5.1 N/mm [P = .04]). In multivariate analysis, the use of the conventional wiring technique (odds ratio, 5.38; P = .04) and osteoporosis (odds ratio, 18.31; P = .0005) were significant risk factors associated with sternal dehiscence. In the patients with osteoporosis (n = 25), the incidence of sternal dehiscence in the reinforced wiring group (4/16 [25%]) was significantly lower than that in the conventional wiring group (7/9 [78%], P = .02). CONCLUSION Osteoporosis is a significant risk factor for sternal dehiscence after bilateral lung transplantation. The new reinforced sternal wiring technique provides biomechanically superior fixation of the sternum and clinically reduces the incidence of sternal dehiscence in high-risk osteoporotic patients undergoing bilateral lung transplantation.
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Affiliation(s)
- Takahiro Oto
- Department of Cardiothoracic Surgery, Heart and Lung Transplant Unit, The Alfred Hospital, Monash University, Melbourne, Australia.
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Braith RW, Conner JA, Fulton MN, Lisor CF, Casey DP, Howe KS, Baz MA. Comparison of alendronate vs alendronate plus mechanical loading as prophylaxis for osteoporosis in lung transplant recipients: a pilot study. J Heart Lung Transplant 2007; 26:132-7. [PMID: 17258146 DOI: 10.1016/j.healun.2006.11.004] [Citation(s) in RCA: 31] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/26/2006] [Revised: 10/19/2006] [Accepted: 11/13/2006] [Indexed: 10/23/2022] Open
Abstract
BACKGROUND Osteoporosis is known to complicate outcomes after lung transplantation (Tx). METHODS To determine the efficacy of bisphosphonate therapy combined with the osteogenic stimulus of mechanical loading, 30 lung transplant recipients (LTRs) were randomly assigned either to alendronate (10 mg/day; n = 10), alendronate (10 mg/day) + resistance exercise (n = 10) or to a control group (n = 10). Alendronate was initiated at 7 days after Tx. Bone mineral density (BMD) of the lumbar spine was measured by dual-energy X-ray absorptiometry before and 2 and 8 months after Tx. Resistance training was initiated at 2 months after Tx and consisted of lumbar extension exercise performed 1 day/week for 6 months. RESULTS Lumbar BMD decreased significantly to below pre-transplant baseline at 2 months after Tx in controls (-12.5 +/- 2.1%), but not in the alendronate (1.5 +/- 1.2%) or alendronate + training (1.5 +/- 0.9%) groups. At 8 months after Tx, lumbar BMD in controls was 14.1 +/- 3.9% below baseline (p < or = 0.05), but was 1.4 +/- 1.1% above baseline in alendronate recipients (p > or = 0.05). The alendronate + training group showed a significantly increased lumbar BMD with values 10.8 +/- 2.3% greater than before Tx. CONCLUSIONS These results suggest that resistance exercise plus alendronate is more effective than alendronate alone in restoring BMD. Anti-osteoporosis therapy in LTRs should include both an anti-resorptive agent and an osteogenic stimulus, such as mechanical loading.
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Affiliation(s)
- Randy W Braith
- Department of Applied Physiology, University of Florida, Gainesville, Florida 32611, USA.
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